Change in Pattern of Muscle Activity. for Torticohs. Following Botulinum Toxin Injections
|
|
- Jessie Shelton
- 6 years ago
- Views:
Transcription
1 Change in Pattern of Muscle Activity Following Botulinum Toxin Injections for Torticohs Douglas J. Gelb, MD, PhD, Don M. Yoshimura, MD,? Richard K. Olney, MD,? Daniel H. Lowenstein, MD,? and Michael J. Aminoff, MD, FRCPi Twenty patients with torticollis had electromyographic studies of their neck muscles performed before and after a series of local injections of botulinum toxin. The pattern of muscle activity changed after the injections, and this effect persisted even after head position had returned to baseline. Patients who did not experience any clinical benefit from the injections also demonstrated a change in the pattern of muscle activity. These results suggest that the underlying abnormality in torticollis usually involves a general motor program for head position, rather than the activity of individual neck muscles. Gelb DJ, Yoshimura DM, Olney RK, Lowenstein DH, Aminoff MJ. Change in pattern of muscle activity following botulinum toxin injections for torticollis. Ann Neurol 1991;29: Local injections of botulinum toxin are effective in treating torticollis [ The beneficial effects are temporary, typically fading after 1 to 3 months. In an earlier study 181, some of our patients reported that their symptoms had returned to baseline even though originally prominent muscles had become flaccid after injection. This suggested that the same abnormal head posture was now being produced by a different pattern of muscle activity. This possibility would be consistent with what is currently known about neck movements in normal subjects. The control system for neck movement has been called overcomplete, or overspecified, in that there are many more muscles available than necessary to accomplish the required movements ~3, 101. Because of this feature, any given neck movement could in principle be produced by a large number of different patterns of muscle activity Theoretical models have been developed to explain how the nervous system might choose from among the large number of possibilities 19, 121, and experimental studies have demonstrated that for any particular task, each neck muscle participates in an identifiable and repeatable manner [lo, 131. Thus, despite the overcomplete nature of the system, the same pattern of neck muscle activity is observed whenever an animal is required to achieve a given head position while performing a given task. By varying the task, however, a different pattern of neck muscle activ- ity may be seen to produce the same head position. This has been demonstrated by comparing reflex and voluntary neck movements in cats [lo], and by varying the force against which human subjects were required to stabilize their head position {lo, 131. Based on these experimental results, one could predict that injection of botulinum toxin into neck muscles of a normal subject would result in a new pattern of muscle activity for any given head position. It is difficult to predict what would occur in a patient with torticollis, however, because the pathogenesis of torticollis is not understood. If torticollis is due to an abnormal motor program, then one might predict that a new pattern of muscle activity would emerge to produce the same abnormal head position despite the injection of botulinum toxin into previously overactive muscles. On the other hand, if torticollis is due to a relatively selective overactivity of individual neck muscles, then no persistent change in the pattern of muscle activity following botulinum toxin injections would be expected. These two alternatives have significant implications, both for understanding the pathophysiology of torticollis and for predicting the likelihood of persistent clinical benefit from local injections of botulinum toxin. We decided to investigate this issue by directly comparing the pattern of muscle activity before and after injections of botulinum toxin. From the *Department of Neurology, University of Michigan, Ann Arbor, MI, and the tdeparcment of Neurology, University of California at San Francisco, San Francisco, CA. Received May 21, 1990, and in revised form Aug 1. Accepred for publication Sep 27, Address correspondence to Dr Gelb, Taubman Center, Department of Neurology, University of Michigan, 1500 bast Medical Center Drive, Ann Arbor, MI Copyright by the American Neurological Association
2 Materials and Methods The treatment design was similar to that used in our earlier but involved a different group of patients. Patients Twenty-two patients, 13 women and 9 men, were enrolled in the study. Two patients dropped out of the study because they observed no benefit from the injections, and experienced mild dysphagia; 1 of these patients had completed only one injection session and the other had completed mo. These patients were considered to be treatment failures in our analysis of clinical response rates, but they were not included in our analysis of electromyogrdphic (EMG) changes. The mean age of the 20 patients who completed the study was 54 years (range, 36 to 70 years), and the mean duration of illness was 8.4 years (range, 1 to 23 years). As in our previous study, patients were given the option of stopping all medications 1 month before entering the study or continuing on their current drug regimen without making any changes during the course of the study; all but 1 chose to do the latter. Injections The muscles that were thought to be most actively contributing to the abnormal head position, either because they were tense in the resting position on clinical examination or because EMG testing demonstrated an abnormal interference pattern, were selected for injection. These were chosen from among three pairs of muscles: the sternocleidomastoid, trapezius, and splenius capitis muscles on each side. Most patients had either three or four muscles injected; 3 patients had five muscles injected, 1 patient had only two muscles injected, and 1 patient had all six muscles injected. Toxin was injected into two to eight sites per muscle, distributed evenly along the length of the muscle. Tsui (personal communication, 1987). had previoilsly determined that injecting one or two sites near the middle of the muscle achieved the same effect as injecting multiple sites throughout the length of the muscle. We chose to inject multiple sites because it permitted a smaller volume per injection site, minimizing patient discomfort. The same muscles and injection sites were used at all sessions for any given patient. There were four injection sessions for each patient. At one session the patient received placebo (saline solution), and at the others the patient received three different doses of botulinum toxin: a base total dose of 120 to 140 units, and half and twice this base dose. At no session did any patient receive more than a total of 280 units, or 180 units to any one muscle. Injection Schedule For each patient, the four injection sessions (one placebo, three different doses of toxin) occurred in random order known to some of the investigators but not the patient or the electromyographer. After each injection session, the patient was seen every 4 weeks, and not reinjected until any benefit (either subjective or objective; see below) from the preceding injection had completely disappeared. Clinical Eealuation SUBJECTIVE. At each clinic visit, patients were asked to rate separately the degree of pain and the severity of the head movements they had been experiencing, using a scale of 1 to 10 for each, with a score of 5 being arbitrarily designated as the baseline state on entering the study. These two scores were then summed to provide a composite subjective scale. As in our previous study, changes from baseline of greater than 20% were considered to be substantial. OBJECTIVE. Patients were videotaped at the time they entered the study and 4 weeks after each injection session, following the standard filming protocol described in our previous paper. The videotapes were rearranged in random order by the photographer after completion of the study and scored independently by the investigators, who were thus blinded with respect to the order of tape presentation. As before, we used the numerical scoring system of Tsui and colleagues { l}: T = [(R + L + E) X D,} + [U X D,], where T is total score, R is rotation (0 = absent, 1 = <15, 2 = 15 to SO, 3 = >30 ); L is lateral head tilt (0 = absent, 1 = mild, 2 = moderate, 3 = severe); E is shoulder elevation or depression (0 = absent, 1 = mild, 2 = severe); U is unsustained movement, such as tremor or jerk (0 = absent, 1 = present); and D, and D, are the durations of sustained and unsustained movements, respectively (1 = intermittent, 2 = continuous). The same scoring system was also used to evaluate the patients at each clinic visit to determine whether any objective benefit from a previous injection persisted. As in our previous study, changes in objective score of at least 3 points were considered to be substantial. Electvophysiological Techniques Each patient was evaluated electrophysiologically at the time of entry into the study and again 4 to 8 weeks after the final injection (in 1 patient, che follow-up EMG was performed 1 week after the final injection, and in 2 patients, it was performed 4 weeks after the third injection). A six-channel EMG recording was collected on a polygraph, with three muscle pairs being studied. Surface electrodes were used to record the activity of the trapezius and sternocleidomastoid muscles on each side, and monopolar needle electrodes were used to record activity of the splenius capitis muscles in reference to surface electrodes placed over the C7 spinous process. Recordings were made on all patients while they were sitting erect, with the head in the spontaneously abnormal position, and then also with the head maintained facing forward so that the torticollis was rcsisted voluntarily for approximately 30 seconds. All six muscles were studied in every patient at each session, regardless of the number of muscles injected. Clearly, it would be optimal to study even deeper muscles as well, but this is not practical in human subjects. Our goal was not to define the precise pattern of muscle activity responsible for the abnormal neck posture, but to determine whether the pattern changed after botulinum toxin injections. Because equipment to rectify and integrate the EMG was not available to us, we devised a descriptive scoring system to grade the level of muscle activity. Thus, each muscle s interference pattern was graded on a scale of 0 to 3 to give each muscle an EMG score. A score of 3 was assigned when Gelb et al: Botulinum Toxin and Torticollis 371
3 Table 1 ~ Number of Patients Showing Response to Botzllinzlm Toxin Response Subjective improvement Subjective deterioration Objective improvement Objective deterioration LOW Intermediate High At Least One Dose Dose Dose Dose Placebo = not applicable (objective response defined as change from placebo score). the EMG recording consisted of a nearly full interference pattern in which individual motor-unit discharges could not be recognized. A score of 2 was assigned if the EMG recording consisted of an interference pattern in which motor units continuously disrupted the baseline but in which individual motor units were often seen. A score of 1 was assigned if the EMG recording reflected nearly continuous recruitment of individually recognizable motor units that did not continuously disrupt the baseline. A score of 0 was assigned if individually recognizable motor units were not activated or were activated less than 10% of the time. A muscle assigned a score of 3 always had more promincnt motor-unit activation than the corresponding muscle on the contralateral side. Scores were generally based on the activity recorded while the head was maintained facing forward. However, when the sternocleidomastoid corrected an abnormal head rotation or the ipsilateral sternocleidomastoid-splenius capitis pair corrected a contralateral head tilt, scoring of these muscles was undertaken when the head was in the spontaneously abnormal position. This was done to minimize any artifact due to voluntary activity of neck muscles compensating for the abnormal head position. Three patients with torticollis who had never received injections of botulinum toxin served as control subjects for the electrophysiological studies, undergoing EMGs on two occasions 1 month apart. Results Clinical Response The subjective and objective response rates (Table 1) were very similar to those found previously. Of the 22 patients who entered the study, 77% (17 patients) showed subjective improvement, substantial in 64% (14 patients). The corresponding numbers in our earlier study {8] were 80% (16 patients) and 55% (1 1 patients). Objective improvement (based on the blinded scores assigned at videotape review) was more frequent in the current study than previously, with 7 of the 22 enrolled patients (32%) showing substantial objective improvement, as opposed to 15% (3 patients) in our prior study. Even so, this higher objective improvement rate was still not statistically significant for any individual toxin dose (p > 0.05, Wil- coxon signed rank test). However, when a composite treatment score (the average of the three scores corresponding to the three different toxin doses) was compared with a control score (the average of the score at baseline and the score after placebo injection) for each patient, the objective improvement was statistically significant (p < 0.01, Wilcoxon signed rank test), in constrast to our previous study. This discrepancy between results using the composite treatment score and scores for individual toxin doses is apparent from inspection of Table 2: in 18 patients, the composite treatment score was lower ( better ) than the control score, and in 2 patients, it was higher. For the lowest dose, scores fell for 10 patients and rose for 6; for the intermediate dose, scores fell for 11 patients and rose for 5; and for the highest dose, scores fell for 11 patients and rose for 4. Side effects and duration of action were similar to our previously published results: subjective benefit typically lasted 1 to 3 months, and the most commonly reported adverse effects were local pain (either at the injection sites or strain in nearby muscles), local weakness, and dysphagia. Electromyographic Results As expected, the EMG score of individual muscles changed after patients received the full course of botulinum toxin injections. The change in EMG score between baseline and follow-up studies for a given muscle was clearly related to the dose of botulinum toxin that had been injected into that muscle (Fig). Although the EMG scores were descriptive, they were assigned by an investigator who did not know which muscles had been injected, or the doses used, so this relationship was not due to biased scoring. The relationship between dose and change in EMG score is also evident from Table 3. Of the muscles injected with a base dose of 40 units or more, 81% of muscles showed a decrease in EMG activity, whereas only 39% of muscles injected with a base dose of 20 units or less did so. By contrast, among noninjected 372 Annals of Neurology Vol 29 No 4 April 1991
4 Table 2. Objectipe Scoresfor All Patients Baed on Videotape Review LOW Intermediate High Composite Control Patient No. Placebo Dose Dose Dose Treatment Scorea Scoreb ? The composite treatment score is the mean of the scores corresponding to the three different doses of botulinum toxin. bthe control score is the mean of the score at baseline and the score after placebo injection. = not available (patient missed the videotape session or tape was lost). loo Average dose for gwen change in EMG score Change in EMG Score Change in EMG score subtracted from Jcore after treatment) plotted against the base da~e of botulinum toxin injected. A negative value rejects a reduction in EMG activity for that muscle. The shaded squares represent the mean base dose for a given change in EMG score. muscles, an increase in EMG score occurred more commonly than did a decrease. In fact, over one-fourth (27%) of noninjected muscles showed an increase in EMG activity, as opposed to only 6% of injected muscles. This difference was statistically significant (z score for the difference between proportions, z = 3.14, p < 0.01). Given the known mechanism of action of botulinum toxin at the neuromuscular junction, it should not be surprising to see a reduction in EMG score and a correlation with dose soon after an injection of botulinum toxin. However, this result would not necessarily be expected in the 6 patients who had received placebo injections at the final session. Since the study design required that all subjective and objective benefits of an injection session should have disappeared before the next injection session could take place, the follow-up EMG study in these patients (performed 2 to 5 months after the last injection of botulinum toxin) should not have reflected the acute effects of the toxin. Yet, even for these patients, injected muscles showed a reduction in EMG score (Table 4). It is unlikely that the placebo injections were somehow acting as a conditioned stimulus, since so few patients showed substantial clinical improvement from placebo. Again, 27% of noninjected muscles showed an increase in EMG activity. Gelb et al: Botulinum Toxin and Torticollis 373
5 Table 3. Changes in EMG Activity in Muscles Injected with Different Base Do.rey of Botulinum Toxin" Any dose Dose 2 40 units 0 < dose 5 20 units Dose = 0 (i.e., not injected) Total No. of Muscles with Decreased EMG Activity with Increased EMG Activity athe base dose was the intermediate dose injected into each muscle. At separate sessions, injections of half the base dose and twice rhe base dose were also administered. The follow-up EMG was performed after all injection sessions had been completed (with two exceptions; see text for details). Table 4. Comparison of EMG Findings Following Injection afhzgh Dose of Botulinum Toxin uith Those Fotlowing Injection of Placebo Injected muscles: highest dose last 19 Injected muscles: placebo lasp 25 Noninjected muscles: placebo lasta 11 Total No. of with Decreased with lncveaed Muscles EMG Activitv EMG Activitv 13 (68%) 9 (36%) 1(9%) "For patients who received their placebo injections 4 weeks before the EMG, the EMG findings in injected muscles and noninjected muscle5 are shown. Thus, even after the original, abnormal head position had returned (and clinical examination showed normal muscle strength), EMG recordings still indicated a change from the baseline pattern of muscle activity. The same conclusion follows from a consideration of those patients who failed to show substantial clinical improvement. Of the 13 patients who did not show substantial objective improvement with any dose, 11 nevertheless showed a convincing change in the pattern of EMG activity, defined as a change in EMG score in at least three muscles. In 7 of these patients, the most active muscle (based on EMG scores) before the injections was no longer the most active muscle after the injections. Similarly, there was a change in the most active muscle identified by EMG studies in 5 of the 6 patients who did not report substantial subjecrive improvement with any dose. In contrast, in the 3 untreated control patients with torticollis, only 1 (8%) of 12 muscles studied showed a reduction in EMG activity, and 1 muscle showed an increase in activity. Discussion This study corroborates our earlier results and those of other investigators {1-8), providing further evidence for the efficacy of local injections of botulinum toxin in the treatment of torticollis. As before, we were unable to show a statistically significant change in objective scores for any individual toxin dose, but we attribute this failure to the insensitivity of the scoring system, as we discussed previously E8, 143. Similar problems are associated with the use of other scoring systems. Despite its limitations, we have continued to use this scoring system because it provides an objective measure by whch our results can be compared with our previous results and those of other authors. The main purpose of the current study was to compare the pattern of muscle activity before and after a series of injections of botulinum toxin. As expected, patients showed a general depression of EMG activity in injected muscles soon after the injections had taken place. The magnitude of this depression correlated with the dose of toxin injected. This depression of EMG activity persisted even after the clinical effects of the injections had disappeared (as shown by the patients who received placebo at their final injection sessions). Moreover, there was a tendency for muscles that had not been injected to show increased EMG activity, and this effect, too, was seen in patients who received placebo at their final injection session. With only one exception, these patients did not report any change from their baseline head position, and none was evident on examination (based on the numerical scoring system). Thus, the same abnormal head position was now associated with a different pattern of muscle activity. It is unlikely that this represents an inherent variability in muscle activity in patients with torticollis, or lack of reproducibility in our EMG scor- 374 Annals of Neurology Vol 29 No 4 April 1991
6 ing system, since untreated patients showed minimal change in muscle activity over time. One might have expected that patients who failed to demonstrate a substantial clinical benefit from any of the injections would also fail to show an appreciable change in the pattern of muscle activity, since their abnormal head position remained constant throughout the study. Contrary to this expectation, a change in the pattern of muscle activity was evident in these patients as well. This was not simply an unmasking of muscles previously active at a low level, for the EMG scores revealed increased activity in individual muscles in the majority of these patients. It is difficult to account for all of these findings purely on the basis of the direct effects of botulinum toxin at the neuromuscular junction. It is conceivable that the persistence of EMG changes beyond the duration of clinical response could simply mean that the EMG is more sensitive than clinical observation; the EMG changes in patients who never demonstrated any clinical change might be interpreted in this way also. However, the inmared EMG activity in noninjected muscles in both of these groups of patients suggests a central, rather than a peripheral reorganization. Were it not for this increase in EMG activity in noninjected muscles, our results could be questioned on methodological grounds. We recorded EMG activity in two head.positions, and chose to base our scoring system primarily on the EMG activity recorded with the head maintained facing forward because it is the more useful one for assessing the muscles that move the head away from a normal position. Some of the EMG activity recorded with the head facing forward may have reflected compensatory activity of muscles not directly involved in producing the abnormal head position. We tried to correct for this (as discussed in the Material and Methods section), but if our correction was not sufficient, some of the reduction in EMG activity seen after injections of botulinum toxin may simply have reflected a reduction in this compensatory muscle activity. This interpretation cannot explain all of our results, however. Since injected muscles were always chosen as the ones whose action contributed to moving the head from the forward to the spontaneously abnormal position, the weakness of the injected muscles should always have made it easier for other muscles to maintain the head in a forward position. While this could result in reduced EMG activity being recorded from these muscles, there is no reason to expect increased activity in any muscles on this basis. Because we studied activity in only six muscles, with the neck in only two positions, the present study does not allow us to draw any conclusions regarding the nature of the motor program itself. It is conceivable, in fact, that head position is controlled by more than one motor program. For example, one program might control tonic activation of neck muscles while another could be related to changes in head position (analogous to the control system for saccadic eye movements). Obviously, more detailed observations would be necessary to investigate these issues. However, our observations were sufficient to demonstrate that the pattern of muscle activity changed after injections of botulinum toxin, and ths was at least partly due to central reorganization. As discussed in the introduction, this conclusion is consistent with the idea that torticollis results from an abnormal motor program. When the most active muscles are functionally denervated by local administration of botulinum toxin, this program may simply call on other muscles to achieve its ends. This conclusion also follows from the results of surgical series, where the abnormal head position eventually recurs despite selective rhizotomy, peripheral nerve section, or muscle section tl5, 163. If other muscles can indeed substitute for the injected muscles to produce the abnormal head position, it might be expected that all patients will eventually fail to benefit from repeated injections of botulinum toxin. However, this has not been our experience, nor that of other investigators 131. Whereas some patients gradually lose their response to botulinum toxin, others continue to experience satisfactory results for at least several years. This may simply reflect a slower adaptation rate, and with continued follow-up these patients may also ultimately fail to respond to repeated injections. Alternatively, there may be two distinct categories of patients with torticollis, possibly reflecting separate pathogenetic mechanisms, or perhaps variations between patients in the degree to which their motor programs adapt to environmental perturbations. Those patients in whom the abnormal motor program produces relatively selective overactivity of certain muscles might experience persistent benefit from repeated injections. By contrast, for patients in whom the motor program abnormality is less dependent on the activity of any particular neck muscle, functional (or actual) denervation might be followed by a fairly rapid emergence of a new pattern of muscle activity. The present study was not designed to address these issues, which remain speculative, but one clear practical result does emerge. We have demonstrated that the pattern of muscle activity in patients with torticollis may change after injections of botulinum toxin, and this should be suspected in patients who initially responded to injections but subsequently fail to do so. This issue could not be addressed directly in the present study, since each patient received a different dose of botulinum toxin at each injection session. An apparent reduction in efficacy could therefore have been a function of the change in dose. However, in patients who fail to respond to previously effective doses, we Gelb et al: Botulinurn Toxin and Torticollis 375
7 recommend performing EMG studies to identify the most active muscles, and adjusting injection sites accordingly. References 1. Tsui JK, Eisen A, Mak E, et al. A pilot study on the use of botdnum toxin in spasmodic torticollis. Can J Neurol Sci 1985; 12: Tsui JK, Eisen A, Stoessl AJ, et al. Double-blind study of botulinum toxin in spasmodic torticollis. Lancet 1986;2: Tsui JK, Fross RD, Calne S, Calne DB. Local treatment of spasmodic torticollis with botulinum toxin. Can J Neurol Sci 1987; 14: Brin MF, Fahn S, Moskowin C, et al. Localized injections of botdnum toxin for the treatment of focal dystonia and hemifacial spasm. Mov Disord 1987;2: Greene P, Shale H, Fahn S, et al. Treatment of torticollis with injections of botulinum toxin. Neurology 1987;37(suppl):123 (Abstract) 6. Jankovic J, Orman J. Botulinum A toxin for cranial-cervical dystonia: a double-blind, placebo-controlled study. Neurology 1987 ;37: Stell R, Thompson PD, Marsden CD. Botulinum toxin in spasmodic torticollis. J Neurol Neurosurg Psychiatry 1988;51: Gelb DJ, Lowenstein DH, Aminoff MJ. Controlled trial of botu- linum toxin injections in the trearment of spsmodic torticoltis. Neurology 1989;39: Pellionisz AJ, Peterson BW. A tensorial model of neck motor activation. In: Peterson BW, Richmond FJ, eds. Control of head movement. New York: Oxford University Press, 1988: Keshner EA, Peterson BW. Motor control strategies underlying head stabilization and voluntary head movements in humans and cats. Prog Brain Res 1988;76: Abbs JH, Cole KJ. Neural mechanisms of motor equivalence and goal achievement. In: Wise SP, ed. Higher brain functions: recent explorations of the brain s emergent properties. New York: Wiley, 1987: Crowninshield RD, Brand RA. A physiologically based criterion of muscle force prediction in locomotion. J Biomechanics 1981; 14: Keshner EA, Campbell D, Karz RT, Peterson BW. Neck muscle activation patterns in humans during isometric head stabilization. Exp Brain Res 1989;75: Gelb UJ, Lowensrein DH, Aminoff MJ. Botulinum toxin type A in the treatment of spasmodic torticollis. Neurology 1989; Pudivinsky F. Torticollis. In: Vinken PJ, Bruyn GW, eds. Handbook of clinical neurology, vol6. Amsterdam: North-Holland, 1968: McCabe JJ. Surgical treatment of spasmodic torticollis. In: Marsden CD, Fahn S, eds. Movement disorders; neurology 2. London: Butterworth, 1982: Annals of Neurology Vol 29 No 4 April 1991
Quantitative Assessment of Botulinum Toxin Treatment in 43 Patients with Head Tremor
~~~~~ ~ ~ Movement Disorder& Vol. 12, NO. 5, 1997, pp 122-126 0 1997 Movemcnt Disorder Society Quantitative Assessment of Botulinum Toxin Treatment in 43 Patients with Head Tremor "tjorg Wissel, "Florian
More informationMYOBLOC and Cervical Dystonia A Patient s Guide
MYOBLOC and Cervical Dystonia A Patient s Guide MYOBLOC (rimabotulinumtoxinb) Injection is indicated for the treatment of adults with cervical dystonia to reduce the severity of abnormal head position
More informationJournal of Anesthesia & Pain Medicine
Case Report To spasm, or Not to Spasm, That is the Question Journal of Anesthesia & Pain Medicine John C McDonald BA 1 and Terence K Gray DO 1,2* 1 Mercy Pain Center, Mercy Hospital, Portland, Maine, USA
More informationBotulinum toxin type A with or without needle electromyographic guidance in patients with cervical dystonia
DOI 10.1186/s40064-016-2967-x RESEARCH Open Access Botulinum toxin type A with or without needle electromyographic guidance in patients with cervical dystonia Chuanjie Wu 1, Fang Xue 2, Wansheng Chang
More informationBOTULINUM TOXIN: RESEARCH ISSUES ARISING FROM PRACTICE
% of baseline CMAP Botulinum toxin: mechanism of action BOTULINUM TOXIN: RESEARCH ISSUES ARISING FROM PRACTICE Clinical benefits of botulinum toxin (BT) injections depend primarily on the toxin's peripheral
More informationScottish Medicines Consortium
Scottish Medicines Consortium clostridium botulinum neurotoxin type A, 100 unit powder for solution for injection (Xeomin ) No. (464/08) Merz Pharma UK Ltd 09 May 2008 The Scottish Medicines Consortium
More informationDOXORUBICIN CHEMOMYECTOMY AS A TREATMENT FOR CERVICAL DYSTONIA: HISTOLOGICAL ASSESSMENT AFTER DIRECT INJECTION INTO THE STERNOCLEIDOMASTOID MUSCLE
ABSTRACT: The sternocleidomastoid muscle (SCM) is one of the major muscles involved in producing abnormal head position in cervical dystonia patients. This study tested whether doxorubicin chemomyectomy,
More informationMUSCLE STRENGTH FOLLOWING DIRECT INJECTION OF DOXORUBICIN INTO RABBIT STERNOCLEIDOMASTOID MUSCLE IN SITU
ABSTRACT: Direct intramuscular injection of doxorubicin results in permanent myofiber loss. A previous phase I trial demonstrated that such injections could successfully treat blepharospasm and hemifacial
More informationTreating Cervical Dystonia. Atul T. Patel, MD, MHSA Vice President, Kansas City Bone & Joint Clinic Overland Park, KS
Treating Cervical Dystonia Atul T. Patel, MD, MHSA Vice President, Kansas City Bone & Joint Clinic Overland Park, KS Disclosures Grant/Research support and Speaker s Bureau for Allegan plc, Merz Pharmaceuticals,
More informationHubert H. Fernandez, MD
Hubert H. Fernandez, MD Associate Professor Co-Director, Movement Disorders Center Director, Clinical Trials for Movement Disorders Program Director, Neurology Residency and Movement Disorders Fellowship
More informationTruncal muscle tonus in progressive supranuclear palsy
190 Department of Neurology, Yokohama City University School of Medicine, Yokohama, Japan A Tanigawa O Hasegawa Department of Neurology, Urafune Hospital, Yokohama City University, Yokohama, Japan A Komiyama
More informationORIGINAL CONTRIBUTION. Sensory Modulation of the Blink Reflex in Patients With Blepharospasm. exhibit an abnormal excitability of the blink reflex
ORIGINAL CONTRIBUTION Sensory Modulation of the Blink Reflex in Patients With Blepharospasm Evelia Gómez-Wong, MD; Maria J. Martí, MD; Eduardo Tolosa, MD; Josep Valls-Solé, MD Objective: To measure the
More informationOutcome of selective ramisectomy for botulinum toxin resistant torticollis
472 Center for Dystonia, Neurological Institute, Columbia-Presbyterian Medical Center B Ford E D Louis P Greene S Fahn Sergievsky Center, Columbia University, New York, USA E D Louis Correspondence to:
More informationTreatment of cervical dystonia with botulinum toxins
European Journal of Neurology 2006, 13 (Suppl. 1): 16 20 Treatment of cervical dystonia with botulinum toxins C. L. Comella a and P. D. Thompson b a Department of Neurological Sciences, Rush University
More informationThis guide describes some of the important facts about Neurobloc that you need to be aware of, however, it does not replace the advice given to you
This guide describes some of the important facts about Neurobloc that you need to be aware of, however, it does not replace the advice given to you by a healthcare professional. Further very important
More informationINTRAOPERATIVE NEUROPHYSIOLOGICAL MONITORING FOR MICROVASCULAR DECOMPRESSION SURGERY IN PATIENTS WITH HEMIFACIAL SPASM
INTRAOPERATIVE NEUROPHYSIOLOGICAL MONITORING FOR MICROVASCULAR DECOMPRESSION SURGERY IN PATIENTS WITH HEMIFACIAL SPASM WILLIAM D. MUSTAIN, PH.D., CNIM, BCS-IOM DEPARTMENT OF OTOLARYNGOLOGY AND COMMUNICATIVE
More informationSupplementary Material for The neural basis of rationalization: Cognitive dissonance reduction during decision-making. Johanna M.
Supplementary Material for The neural basis of rationalization: Cognitive dissonance reduction during decision-making Johanna M. Jarcho 1,2 Elliot T. Berkman 3 Matthew D. Lieberman 3 1 Department of Psychiatry
More informationTHE CLINICAL USE OF BOTULINUM TOXIN IN THE TREATMENT OF MOVEMENT DISORDERS, SPASTICITY, AND SOFT TISSUE PAIN
THE CLINICAL USE OF BOTULINUM TOXIN IN THE TREATMENT OF MOVEMENT DISORDERS, SPASTICITY, AND SOFT TISSUE PAIN Spasmodic torticollis (cervical dystonia), blepharospasm, and writer s cramp are specific types
More informationHealth related quality of life is improved by botulinum neurotoxin type A in long term treated patients with focal dystonia
J Neurol Neurosurg Psychiatry 21;71:193 199 193 Klinik und Poliklinik für Neurologie, der Universität zu Köln, Joseph-Stelzmann- Strasse 9, D- 5924 Köln Germany R Hilker M Schischniaschvili M Ghaemi A
More informationSee Important Reminder at the end of this policy for important regulatory and legal information.
Clinical Policy: (Myobloc) Reference Number: CP.PHAR.233 Effective Date: 07.01.16 Last Review Date: 05.18 Line of Business: Commercial, Medicaid Coding Implications Revision Log See Important Reminder
More informationElectrical stimulation for reducing trapezius muscle dysfunction in cancer patients: traditional treatment protocols also work
Electrical stimulation for reducing trapezius muscle dysfunction in cancer patients: traditional treatment protocols also work RE: Baldwin ERL, Baldwin TD, Lancaster JS, et al. Neuromuscular electrical
More informationCentral and peripheral fatigue in sustained maximum voluntary contractions of human quadriceps muscle
Clinical Science and Molecular Medicine (1978) 54,609-614 Central and peripheral fatigue in sustained maximum voluntary contractions of human quadriceps muscle B. BIGLAND-RITCHIE*, D. A. JONES, G. P. HOSKING
More informationFIXED-RATIO PUNISHMENT1 N. H. AZRIN,2 W. C. HOLZ,2 AND D. F. HAKE3
JOURNAL OF THE EXPERIMENTAL ANALYSIS OF BEHAVIOR VOLUME 6, NUMBER 2 APRIL, 1963 FIXED-RATIO PUNISHMENT1 N. H. AZRIN,2 W. C. HOLZ,2 AND D. F. HAKE3 Responses were maintained by a variable-interval schedule
More informationThe treatment of adductor spasmodic dysphonia. Information for patients
The treatment of adductor spasmodic dysphonia Information for patients What is spasmodic dysphonia? This is a form of dystonia, a neurological condition causing involuntary muscle spasms in the larynx
More informationSomatic Adaptation in Cerebral Palsy LINKING ASSESSMENT WITH TREATMENT: AN NDT PERSPECTIVE. By W. Michael Magrun, M.S., OTR/L
Somatic Adaptation in Cerebral Palsy LINKING ASSESSMENT WITH TREATMENT: AN NDT PERSPECTIVE By W. Michael Magrun, M.S., OTR/L INTRODUCTION Somatic adaptation is one of the primary functions of the central
More informationSurvey of practices employed by neurologists for the definition and management of secondary nonresponse to botulinum toxin in cervical dystonia
Survey of practices employed by neurologists for the definition and management of secondary nonresponse to botulinum toxin in cervical dystonia Joaquim J. Ferreira, MD, PhD a Roongroj Bhidayasiri, MD b,c
More informationSee Important Reminder at the end of this policy for important regulatory and legal information.
Clinical Policy: (Xeomin) Reference Number: CP.PHAR.231 Effective Date: 07.01.16 Last Review Date 05.18 Line of Business: Commercial, HIM, Medicaid Coding Implications Revision Log See Important Reminder
More informationDystonia: Title. A real pain in the neck. in All the Wrong Places
Focus on CME at the University of Western Ontario Dystonia: Title in All the Wrong Places A real pain in the neck By Mandar Jog, MD, FRCPC and; Mary Jenkins, MD, FRCPC What is dystonia? Dystonia is a neurologic
More informationCervical Dystonia. One type of dystonia Julie Rope
Cervical Dystonia One type of dystonia Julie Rope Cervical Dystonia Patterned, repetitive, and spasmodic or sustained muscle contractions resulting in abnormal movements and postures of the head and neck
More informationSee Important Reminder at the end of this policy for important regulatory and legal information.
Clinical Policy: (Dysport) Reference Number: CP.PHAR.230 Effective Date: 07.01.16 Last Review Date: 05.18 Line of Business: Commercial, HIM, Medicaid Coding Implications Revision Log See Important Reminder
More informationIN ADUL T SUBJECTS WITH BLEPHAROSPASM ACROSS DOSING INTE R VAL S
Poster number 609 INCOBOT UL INUMT OXINA (NT -201) I NJ E C T I ONS A R E SAFE AND EFFECTIVE IN ADUL T SUBJECTS WITH BLEPHAROSPASM ACROSS DOSING INTE R VAL S IN A REPEATED DOSE ST UDY Matthew Brodsky,
More informationat least in part, by observing the effect of raising body temperature on the evoked potentials. upper limit of the normal value for latency of
Journal of Neurology, Neurosurgery, and Psychiatry, 1979, 42, 250-255 Effect of raising body temperature on visual and somatosensory evoked potentials in patients with multiple sclerosis W. B. MATTHEWS,
More informationHemifacial spasm. Parkinson's Disease Center and Movement Disorders Clinic
Parkinson's Disease Center and Movement Disorders Clinic 7200 Cambridge Street, 9th Floor, Suite 9A Houston, Texas 77030 713-798-2273 phone www.jankovic.org Hemifacial spasm Diagnosis Hemifacial spasm
More informationOBSERVATIONS ON THE REACTION TIME TO CUTANEOUS
J. Neurol. Neurosurg. Psychiat., 1955, 18, 120. OBSERVATIONS ON THE REACTION TIME TO CUTANEOUS THERMAL STIMULI BY P. P. LELE* and D. C. SINCLAIR From the Department of Anatomy, University of Oxford The
More informationPART ONE. The Nature of Badminton
PART ONE The Nature of Badminton 1 The Requirements of the Game In order to write a book on fitness-training and to recommend appropriate and realistic training methods it is necessary to be clear about
More informationPhenomenology of Movement Disorders
Phenomenology of Movement Disorders Raja Mehanna MD Anatomical reasoning Anatomical reasoning Phenomenological reasoning Abnormal movement Hypokinetic Hyperkinetic Ataxia Video 1 But there is a tremor!
More informationErgonomic Test of the Kinesis Contoured Keyboard
Global Ergonomic Technologies, Inc. Ergonomic Test of the Kinesis Contoured Keyboard Prepared by Wanda Smith, President Dan Cronin, Engineer December 16, 1992 Executive Summary A study was conducted of
More informationDiagnostic Delays in Spasmodic Dysphonia: A Call for Clinician Education
Diagnostic Delays in Spasmodic Dysphonia: A Call for Clinician Education Francis X. Creighton, Harvard University Edie Hapner, Emory University Adam Klein, Emory University Ami Rosen, Emory University
More informationPallidal Deep Brain Stimulation
Pallidal Deep Brain Stimulation Treatment for Dystonia Dystonia Dystonia is a neurological disorder characterized by involuntary muscle contractions resulting in abnormal postures. These movements may
More informationNational Hospital for Neurology and Neurosurgery
National Hospital for Neurology and Neurosurgery Neurophysiological testing in patients with suspected or confirmed muscle channelopathies Centre for Neuromuscular Diseases Contents 1. Introduction 2.
More informationHARVARD PILGRIM HEALTH CARE RECOMMENDED MEDICATION REQUEST GUIDELINES
Generic Brand HICL GCN Exception/Other ONABOTULINUMTOXINA BOTOX 04867 BRAND BOTOX COSMETIC ABOBOTULINUMTOXINA DYSPORT 36477 RIMABOTULINUMTOXINB MYOBLOC 21869 INCOBOTULINUMTOXINA XEOMIN 36687 Please use
More informationClare Gaduzo BSc RMN Registered Aesthetics Practitioner (qualified with Medics Direct)
Clare Gaduzo BSc RMN Registered Aesthetics Practitioner (qualified with Medics Direct) 07935567067 cjg.aesthetics@yahoo.co.uk www.cjgaesthetics.co.uk http://www.facebook.com/cjgaesthetics @CJGAesthetics
More informationDouble dissociation of value computations in orbitofrontal and anterior cingulate neurons
Supplementary Information for: Double dissociation of value computations in orbitofrontal and anterior cingulate neurons Steven W. Kennerley, Timothy E. J. Behrens & Jonathan D. Wallis Content list: Supplementary
More informationEvaluation of the Edrophonium Challenge Test for Cervical Dystonia
doi: 1.2169/internalmedicine.8555-16 Intern Med Advance Publication http://internmed.jp ORIGINAL ARTICLE Evaluation of the Edrophonium Challenge Test for Cervical Dystonia Shinichi Matsumoto 1, Nagahisa
More informationORIGINAL CONTRIBUTION
ORIGINAL CONTRIBUTION Common Misdiagnosis of a Common Neurological Disorder How Are We Misdiagnosing Essential Tremor? Samay Jain, MD; Steven E. Lo, MD; Elan D. Louis, MD, MS Background: As a common neurological
More informationClinical Policy: IncobotulinumtoxinA (Xeomin) Reference Number: CP.PHAR.231
Clinical Policy: (Xeomin) Reference Number: CP.PHAR.231 Effective Date: 07/16 Last Review Date: 07/17 Coding Implications Revision Log See Important Reminder at the end of this policy for important regulatory
More informationDystonia. The condition can vary from very mild to severe. Dystonia may get worse over time or it may stay the same or get better.
Dystonia What are movement disorders? Movement disorders are conditions that cause involuntary body movements. With all movement disorders, abnormal signals from the brain cause patients to have trouble
More informationPearce, Catharine. Downloaded 22-Oct :14:
Is using a patient s estimated lean body mass a suitable method of predicting their eventual therapeutic units of botulinum toxin for the treatment of cervical dystonia? Item type Authors Other Pearce,
More informationBotox. Botox (onabotulinum toxin A) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.75.01 Subject: Botox Page: 1 of 8 Last Review Date: September 15, 2017 Botox Description Botox (onabotulinum
More informationAS THE LEADING CAUSE of job-related disability and
ORIGINAL ARTICLE Therapeutic Use of Botulinum Toxin Type A in Treating Neck and Upper-Back Pain of Myofascial Origin: A Pilot Study Henry L. Lew, MD, PhD, Eun Ha Lee, MD, PhD, Annabel Castaneda, MD, MPH,
More informationNeuromuscular Consequences of Reflexive Covert Orienting
Neuromuscular Consequences of Reflexive Covert Orienting Brian D. Corneil, Douglas P. Munoz, Brendan B. Chapman, Tania Admans, Sharon L. Cushing Fixation Cue (3 ms) CTOA 5, 2 or 6 ms Fixation Target Supplementary
More informationBody position and eerebrospinal fluid pressure. Part 2' Clinical studies on orthostatic pressure and the hydrostatic indifferent point
Body position and eerebrospinal fluid pressure Part 2' Clinical studies on orthostatic pressure and the hydrostatic indifferent point BJORN MAGNAES, M.D. Department of Neurosurgery, Rikshospitalet, Oslo
More informationExploration and Exploitation in Reinforcement Learning
Exploration and Exploitation in Reinforcement Learning Melanie Coggan Research supervised by Prof. Doina Precup CRA-W DMP Project at McGill University (2004) 1/18 Introduction A common problem in reinforcement
More informationBotulinum toxin treatment of cranial-cervical dystonia, spasmodic dysphonia, other focal dystonias and hemifacial spasm
Journal of Neurology, Neurosurgery, and Psychiatry 990;53:633-639 Department of Neurology, Baylor College of Medicine, Houston, Texas, United States J Jankovic K Schwartz Department of Otorhinolaryngology,
More informationStatic and Dynamic Balance Function in Spasmodic Torticollis
Movement Disorders Vol. 14, No. 1, 1999, pp. 87 94 1999 Movement Disorder Society Static and Dynamic Balance Function in Spasmodic Torticollis *Marion Simonetta Moreau, MD, PhD, Alexandra Séverac Cauquil,
More informationClinical Policy: IncobotulinumtoxinA (Xeomin) Reference Number: ERX.SPA.194 Effective Date:
Clinical Policy: (Xeomin) Reference Number: ERX.SPA.194 Effective Date: 01.11.17 Last Review Date: 11.18 Revision Log See Important Reminder at the end of this policy for important regulatory and legal
More informationEffects of Sequential Context on Judgments and Decisions in the Prisoner s Dilemma Game
Effects of Sequential Context on Judgments and Decisions in the Prisoner s Dilemma Game Ivaylo Vlaev (ivaylo.vlaev@psy.ox.ac.uk) Department of Experimental Psychology, University of Oxford, Oxford, OX1
More informationWhat is dystonia? Types of dystonia
My Dystonia Journey My Dystonia Journey My name is Liam Carbery and I suffer from generalised dystonia affecting most of my body. I hope when you are reading this, it will give you an insight into the
More informationSurface recording of muscle activity
3 rd Congress of the European Academy of Neurology Amsterdam, The Netherlands, June 24 27, 2017 Hands-on Course 5 Electromyography: Surface, needle conventional and single fiber - Level 1-2 Surface recording
More informationTension-Type Headache
Chronic Headache Tension-Type Headache Its mechanism and treatment JMAJ 47(3): 130 134, 2004 Manabu SAKUTA Chief Professor, First Internal Medicine (Neurology), Kyorin University Abstract: Tension-type
More informationCrossed flexor reflex responses and their reversal in freely walking cats
Brain Research, 197 (1980) 538-542 0 Elsevier/North-Holland Biomedical Press Crossed flexor reflex responses and their reversal in freely walking cats J. DUYSENS*, G. E. LOEB and B. J. WESTON Laboratory
More informationDiagnostic cervical and lumbar medial branch blocks
Considered Judgement Form This form is a checklist of issues that may be considered by the Purchasing Guidance Advisory Group when making purchasing recommendations Meeting date: 2 November 2015 Topic:
More informationEvaluating Movement Posture Disorganization
Evaluating Movement Posture Disorganization A Criteria-Based Reference Format for Observing & Analyzing Motor Behavior in Children with Learning Disabilities By W. Michael Magrun, MS, OTR 3 R D E D I T
More informationGuide to the use of nerve conduction studies (NCS) & electromyography (EMG) for non-neurologists
Guide to the use of nerve conduction studies (NCS) & electromyography (EMG) for non-neurologists What is NCS/EMG? NCS examines the conduction properties of sensory and motor peripheral nerves. For both
More informationThe individual animals, the basic design of the experiments and the electrophysiological
SUPPORTING ONLINE MATERIAL Material and Methods The individual animals, the basic design of the experiments and the electrophysiological techniques for extracellularly recording from dopamine neurons were
More informationCEDAC FINAL RECOMMENDATION
CEDAC FINAL RECOMMENDATION CLOSTRIDIUM BOTULINUM NEUROTOXIN TYPE A, FREE FROM COMPLEXING PROTEINS (Xeomin Merz Pharma Canada Ltd.) Indication: Blepharospasm Recommendation: The Canadian Expert Drug Advisory
More informationo^ &&cvi AL Perceptual and Motor Skills, 1965, 20, Southern Universities Press 1965
Ml 3 Hi o^ &&cvi AL 44755 Perceptual and Motor Skills, 1965, 20, 311-316. Southern Universities Press 1965 m CONFIDENCE RATINGS AND LEVEL OF PERFORMANCE ON A JUDGMENTAL TASK 1 RAYMOND S. NICKERSON AND
More informationNeurophysiological study of tremor: How to do it in clinical practice
3 rd Congress of the European Academy of Neurology Amsterdam, The Netherlands, June 24 27, 2017 Hands-on Course 8 MDS-ES/EAN: Neurophysiological study of tremor - Level 1 Neurophysiological study of tremor:
More informationFactors affecting the health-related quality of life of patients with cervical dystonia and the impact of botulinum toxin type A injections
Factors affecting the health-related quality of life of patients with cervical dystonia and the impact of botulinum toxin type A injections Jaroslaw Slawek a Andrzej Friedman b Anna Potulska b Pierre Krystkowiak
More informationInformed Consent Form
Informed Consent Form Botox Cosmetic (onabotulinumtoxin A) Dysport (abobotulinumtoxin A) Xeomin (incobotulinumtoxin A) INSTRUCTIONS This is an informed-consent document that has been prepared to help inform
More informationFor carers and relatives of people with frontotemporal dementia and semantic dementia. Newsletter
For carers and relatives of people with frontotemporal dementia and semantic dementia Newsletter AUGUST 2008 1 Welcome Welcome to the August edition of our CFU Support Group Newsletter. Thanks to all of
More informationThe Immediate Reproducibility of T Wave Alternans During Bicycle Exercise
Reprinted with permission from JOURNAL OF PACING AND CLINICAL ELECTROPHYSIOLOGY, Volume 25, No. 8, August 2002 Copyright 2002 by Futura Publishing Company, Inc., Armonk, NY 10504-0418. The Immediate Reproducibility
More informationOriginal Article. Annals of Rehabilitation Medicine INTRODUCTION
Original Article Ann Rehabil Med 2013;37(6):777-784 pissn: 2234-0645 eissn: 2234-0653 http://dx.doi.org/10.5535/arm.2013.37.6.777 Annals of Rehabilitation Medicine Threshold of Clinical Severity of Cervical
More informationBotulinum toxin type A in the treatment of patients with cervical dystonia
REVIEW Botulinum toxin type A in the treatment of patients with cervical dystonia Allison Brashear Dept of Neurology, Wake Forest University Baptist, Medical Center, Winston Salem, NC, USA Correspondence:
More informationChapter 5: Field experimental designs in agriculture
Chapter 5: Field experimental designs in agriculture Jose Crossa Biometrics and Statistics Unit Crop Research Informatics Lab (CRIL) CIMMYT. Int. Apdo. Postal 6-641, 06600 Mexico, DF, Mexico Introduction
More informationNeuromuscular Blocking Agents
Neuromuscular Blocking Agents DRUG POLICY This Prior Authorization request will be reviewed for medical necessity only. Benefits are subject to the terms and conditions of the patient s contract. Please
More informationMemory Storage as a Function of Arousal and Time with Homogeneous and Heterogeneous Lists
..IURNAL F VERBAL LEARNING AND VERBAL BEI~AVIR 9., 113-119 (1963) Memory Storage as a Function of Arousal and Time with Homogeneous and Heterogeneous Lists This study is based: on a general theory which
More informationHeadache and Migraine Treatment
Many of us think of Botox primarily as a cosmetic treatment for lines and wrinkles on the face, but the botulinum toxin that Botox is derived from has a long history of medically therapeutic uses. In fact,
More informationNational Institute for Health and Clinical Excellence
National Institute for Health and Clinical Excellence 319 Deep brain stimulation for tremor and dystonia (excluding Parkinson s disease) nts table IPAC date: 16 June 2006 Consultee name nts The Dystonia
More informationCervical reflex Giovanni Ralli. Dipartimento di Organi di Senso, Università di Roma La Sapienza
Cervical reflex Giovanni Ralli Dipartimento di Organi di Senso, Università di Roma La Sapienza The development of the neck in vertebrates allows the individual to rotate the head independently of the trunk
More informationRegression Discontinuity Analysis
Regression Discontinuity Analysis A researcher wants to determine whether tutoring underachieving middle school students improves their math grades. Another wonders whether providing financial aid to low-income
More informationTHE USE OF MULTIVARIATE ANALYSIS IN DEVELOPMENT THEORY: A CRITIQUE OF THE APPROACH ADOPTED BY ADELMAN AND MORRIS A. C. RAYNER
THE USE OF MULTIVARIATE ANALYSIS IN DEVELOPMENT THEORY: A CRITIQUE OF THE APPROACH ADOPTED BY ADELMAN AND MORRIS A. C. RAYNER Introduction, 639. Factor analysis, 639. Discriminant analysis, 644. INTRODUCTION
More informationBOTOX. Description. Section: Prescription Drugs Effective Date: January 1, 2013 Subsection: CNS Original Policy Date: December 7, 2011
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.12.01 Subject: Botox Page: 1 of 6 Last Review Status/Date: December 6, 2012 BOTOX Description Botox (onabotulinum
More informationON THE MUSCULAR ACTIVITY OF THE PERFORMING VIOLINIST
ON THE MUSCULAR ACTIVITY OF THE PERFORMING VIOLINIST Knut Guettler, Hege Jahren, Karl Hartviksen, Torgeir Nesse and Ørnulf Boye Hansen. The Norwegian State Academy of Music P.Box 5190 Majorstua, 0302 Oslo,
More informationYawning: A Possible Confounding Variable in EMG Biofeedback Studies
Yawning: A Possible Confounding Variable in EMG Biofeedback Studies Biofeedback and Self-Regulation, Vol. 14, No. 4, 1989 R. E. Oman Centre de Recherche, Institut de Réadaptation de Montieal, and Université
More informationThe RoB 2.0 tool (individually randomized, cross-over trials)
The RoB 2.0 tool (individually randomized, cross-over trials) Study design Randomized parallel group trial Cluster-randomized trial Randomized cross-over or other matched design Specify which outcome is
More informationEMR template and postprocedure notes
EMR template and postprocedure notes Sample autopopulated text to create a BOTOX injection procedure report Information gathered from market research. These considerations are for reference only and should
More informationApproach to a Neurologic Diagnosis
Approach to a Neurologic Diagnosis Neurologic Diagnosis History Physical & Neurological Examination Ancillary Procedures 3 Questions Asked Focal neurologic deficits Increased intracranial pressure Signs
More information(Received 10 April 1956)
446 J. Physiol. (I956) I33, 446-455 A COMPARISON OF FLEXOR AND EXTENSOR REFLEXES OF MUSCULAR ORIGIN BY M. G. F. FUORTES AND D. H. HUBEL From the Department ofneurophysiology, Walter Reed Army Institute
More informationPlacename CCG. Policies for the Commissioning of Healthcare
Placename CCG Policies for the Commissioning of Healthcare Policy for the funding of insulin pumps and continuous glucose monitoring devices for patients with diabetes 1 Introduction 1.1 This document
More informationBotox , The Patient Education Institute, Inc. rxf60101 Last reviewed: 01/11/2018 1
Botox Introduction Botox is a well known brand name for a medicinal form of a toxin, or poison. When injected in small doses into specific muscles, Botox doesn't poison you. Instead, it acts as a muscle
More informationThe recommended method for diagnosing sleep
reviews Measuring Agreement Between Diagnostic Devices* W. Ward Flemons, MD; and Michael R. Littner, MD, FCCP There is growing interest in using portable monitoring for investigating patients with suspected
More informationCONTROL OF IMPULSIVE CHOICE THROUGH BIASING INSTRUCTIONS. DOUGLAS J. NAVARICK California State University, Fullerton
The Psychological Record, 2001, 51, 549-560 CONTROL OF IMPULSIVE CHOICE THROUGH BIASING INSTRUCTIONS DOUGLAS J. NAVARICK California State University, Fullerton College students repeatedly chose between
More informationINVESTIGATING FIT WITH THE RASCH MODEL. Benjamin Wright and Ronald Mead (1979?) Most disturbances in the measurement process can be considered a form
INVESTIGATING FIT WITH THE RASCH MODEL Benjamin Wright and Ronald Mead (1979?) Most disturbances in the measurement process can be considered a form of multidimensionality. The settings in which measurement
More informationAssessing risk of bias
Assessing risk of bias Norwegian Research School for Global Health Atle Fretheim Research Director, Norwegian Institute of Public Health Professor II, Uiniversity of Oslo Goal for the day We all have an
More informationRECALL OF PAIRED-ASSOCIATES AS A FUNCTION OF OVERT AND COVERT REHEARSAL PROCEDURES TECHNICAL REPORT NO. 114 PSYCHOLOGY SERIES
RECALL OF PAIRED-ASSOCIATES AS A FUNCTION OF OVERT AND COVERT REHEARSAL PROCEDURES by John W. Brelsford, Jr. and Richard C. Atkinson TECHNICAL REPORT NO. 114 July 21, 1967 PSYCHOLOGY SERIES!, Reproduction
More informationForm B3L: UPDRS Part III Motor Examination 1
Initial Visit Packet NACC Uniform Data Set (UDS) LBD MODULE Form B3L: UPDRS Part III Motor Examination 1 ADC name: Subject ID: Form date: / / Visit #: Examiner s initials: INSTRUCTIONS: This form is to
More informationEBCC Data Analysis Tool (EBCC DAT) Introduction
Instructor: Paul Wolfgang Faculty sponsor: Yuan Shi, Ph.D. Andrey Mavrichev CIS 4339 Project in Computer Science May 7, 2009 Research work was completed in collaboration with Michael Tobia, Kevin L. Brown,
More informationHarald Hefter, 1 Christian Hartmann, 1 Ulrike Kahlen, 1 Marek Moll, 1 Hans Bigalke 2
Open Access Research Prospective analysis of neutralising antibody titres in secondary non-responders under continuous treatment with a botulinumtoxin type A preparation free of complexing proteins a single
More information